Page 39 - Journal of WALS

Sagar Basanale

groups published one of the largest nonrandomized studies. single case of port site recurrence in the laparoscopic group
Data from 102 consecutive patients who underwent laparoscopic (n = 106) as compared to none in the open group (n = 102), after
colorectal resection were reviewed and compared to 641 patients a median follow-up of 43 months. Early high incidence of port
who had an open procedure at the same institution and with the metastasis was probably because enthusiastic laparoscopic
National Cancer Data Base (NCDB), including 36,947 patients surgeons ignored oncological principles.
during a similar time period; complete 5-year survival data were Another concern is regarding the accidental tumor spillage
attained for 93% of the laparoscopically treated patients. during laparoscopic colorectal resections that is caused by
Overall, the mean follow-up time was 64.4 months; patients grasping and manipulating the bowel in the narrow pelvis. The
who died were excluded. The 5-year relative survival rates in prevalence of intraoperative tumor cell dissemination that is
the laparoscopic group were 73% for stage I, 61% for stage II, caused by iatrogenic tumor perforation or transaction during
55% for stage III and 0% for stage IV disease. These results laparoscopic APR has been reported to be as high as 5%.
were comparable to the open group and the NCDB data which At the moment, there are few large studies more than 50 patients
showed a survival rate of 75% and 70% for stage I, 65% and and 3 years follow-up. In two series, where patients underwent
60% for stage II, 46% and 44% for stage III, and 11% and 7% for laparoscopic rectal resection for advanced tumor, local pelvic
stage IV disease respectively. Finally, the overall Kaplan-Meier recurrence rates were 19% and 25%, quite similar to recurrence
5-year survival curve for patients treated by laparoscopy was rate in the open group.
54%, including all stages of disease, and 64% for stage I to III In CLASICC trial, 7,242 rectal resections were performed
diseases.
and conversion rate ranges from 34% for rectal cancer as
opposed to 25% for colonic cancer. Rate of positive margins
RECURRENCE RATES
were not statistically difficult. This clearly demonstrates that
Large number of retrospective and prospective series have laparoscopic rectal resection even in the hands of experienced
reported recurrence rates after curative resection. These studies surgeons is more technically demanding than laparoscopic
have had a mean/median follow-up time from 16 to 71 months; colonic surgery. Although large randomized, prospective trials
recurrence rates varied from 7.2 to 16.1%, including local may show that experienced laparoscopic colectomists can
recurrences from 1.5 to 4.1% and distant recurrences from 6.1 to achieve good outcomes for patients who have curable
10.3%. In contrast to earlier reports, port/extraction site intraperitoneal colon adenocarcinoma, these results cannot be
recurrence rates do not seem to surpass 1% after curative extrapolated immediately to patients who have rectal cancer.
resection in the majority of recent studies. Thus, it is critical to evaluate immediate pathology and long-
Comparative studies have found equivalent recurrence rates term oncological results of laparoscopic proctectomy
between laparoscopy and laparotomy with an overall rate of prospectively, before recommending the technique for mass
approximately 4.6 and 20% for both groups. Local recurrences consumption.
have reached up to 14.8 and 26% and distant recurrences up to
15 and 18.6% in the laparoscopic and open groups respectively. SUMMARY

PORT SITE METASTASIS AND Laparoscopy for colorectal cancer has shown to be superior to
TUMOR DISSEMINATION laparotomy in regard to short-term benefits, including pain,
length of ileus, length of hospitalization, cosmesis, morbidity
In 1993, Alexander et al reported a case of wound recurrence
after 3 months following laparoscopic right hemicolectomy for and disability. When performed by appropriately skilled
a Dukes C adenocarcinoma. After this, there were flood of reports surgeons in properly selected patients, these short-term benefits
of increased port site metastasis with laparoscopy for are almost always demonstrated. Since the publication of the
malignancy. COST trial, it appears that laparoscopic colectomy and
In a critical review of the literature from 2001, Zmora et al conventional open colectomy have similar long-term outcomes.
analyzed total of 16 series of laparoscopic colorectal resections Fundamental differences exist between the Lacy trial and the
for carcinoma, published between 1993 and 2000, each COST trial. The former study included patients all of whom
comprising of greater than 50 patients and found an incidence were operated upon by a single highly skilled surgeon with a
of port site metastasis of less than 1% among 1,737 patients. team devoted to laparoscopic resection. The latter study
More recently, the data from well-designed randomized included a myriad, if surgeons with a wide range of backgrounds
controlled trials have provided definitive evidence against a entering a variable number of cases per surgeon. The COST
higher incidence of port site metastasis in laparoscopic colon trial may therefore better reflect the typical community standard
surgery compared with traditional resection. The clinical than the Lacy trial. However, the Lacy trial which found
outcomes of surgical therapy (COST) study reported a wound superiority relative to recurrence and survival in favor of
recurrence rate of 0.5% in laparoscopy group compared with a laparoscopy suggests that, in the hands of skilled laparoscopic
0.2% in the open group (n = 872, p = 0.50). Lacy et al found a surgeons performing a high volume of this technique in the

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